The mini-Bentall approach: Comparison with full sternotomy

Abstract

Background: The upper mini sternotomy Bentall (mini-Bentall) procedure may result in less trauma and earlier recovery compared with the full sternotomy Bentall procedure (full Bentall). This study compares immediate and 1-and 3-year survival rates after mini-and full Bentall procedures. Methods: Between February 2009 and July 2019, 48 patients underwent a mini-Bentall and 49 underwent a full Bentall. Patients who required concomitant procedures, reoperations, or hypothermic circulatory arrest were excluded from our analysis. The mean patient age was 60.7 years in the mini-Bentall group and 59.0 years in the full Bentall group. Results: There were no in-hospital mortalities. The median cardiopulmonary bypass time (mini-Bentall: 165 minutes [interquartile range (IQR), 155.5-183 minutes]; full Bentall: 164 minutes [IQR, 150-187 minutes]; P ¼ .619) and aortic cross-clamp times (139 minutes [IQR, 128.5-153 minutes] vs 137 minutes [IQR, 125-156 minutes]; P ¼ .948) were not significantly different between the 2 groups. The mini-Bentall group had a significantly shorter median ventilation time compared with the full Bentall group (5.5 hours [IQR, 3-14 hours] vs 17 hours [IQR, 11-23 hours]; P<.001). None of the patients in the mini-Bentall group had postoperative bleeding necessitating reoperation, whereas 4 patients (8.2%) underwent reoperation after full Bentall (P ¼ .043). The mini-Bentall group also had a shorter median hospital length of stay (6 days [IQR, 5-8 days] vs 7 days [IQR, 6-8 days]; P ¼ .086). Survival at 1 and 3 years was 100% in both cohorts.Conclusions: Patients required significantly less ventilation time and reoperations for bleeding after the mini-Bentall procedure. There were no significant differences in cardiopulmonary bypass, aortic cross-clamp times, or intensive care unit and hospital length of stay between the mini-Bentall and full Bentall groups. The mini-Bentall approach is associated with low morbidity and mortality. (JTCVS Techniques 2021;7:59-66) J-type mini-sternotomy.

How We Perform a David Procedure With an Upper Hemisternotomy Approach

“…There was no hospital or 30-day mortalities in either cohort (Table 3). Additionally, there were no significant differences in median intensive care unit (ICU) stay (3 [2-3.5] vs 3 [2][3][4] days, P = 0.739) or hospital stay (6 [6-7] vs 7 [6][7][8][9] days, P = 0.115) between the UHS and FS cohorts. In the FS cohort, 1 patient (3.7%) had a postoperative transient ischemic attack.…”

“…11 All MIS aortic root operations are based on the same several fundamental tenets of optimal exposure, safe cannulation and cardioplegia strategies, use of facilitating technologies, meticulous hemostasis, and the surgeon's ability to master the learning curve. 4,6,10 The UHS incision affords excellent exposure of the ascending aorta and arch for cannulation and distal anastomosis. Strategically placed pericardial traction sutures bring the aorta to the midline and near the sternum.…”

“…These patients are not candidates for the UHS approach due to need for greater operative exposure and higher technical complexity. 5,6 In patients with acute type A aortic dissections confined to the proximal aorta and aortic root, we avoid UHS and perform FS in all patients to precisely assess involvement of the coronary arteries and the attendant risks for coronary artery malperfusion and myocardial ischemia. Patients were identified from a prospectively maintained aortic registry containing demographic, clinical, operative, and postoperative data; their data were studied retrospectively.…”

Commentary: The mini-Bentall approach: Small and safe!

“… 3 , 4 The variety of operations for which a less invasive approach is technically feasible has been continuously expanded to more complex operations, such as aortic or mitral valve disease, multivessel coronary artery grafting, and even aortic surgery involving the arch. 5 , 6 , 7 In this issue of JCTVS Techniques , Shah and coworkers 8 report their institutional experience with a minimally invasive “mini-Bentall” procedure via a partial upper sternotomy and compare mid-term results with those from the conventional full sternotomy approach. In the downloadable narrative video, the authors nicely demonstrate their surgical technique with the mini-Bentall via an upper hemisternotomy and provide useful hints for preventing surgical complications attributed to the limited access site.…”

Commentary: The rise of minimalism in cardiac surgery

“… 1 The evolution of minimally invasive surgery has been fast, beginning with initial attempts at coronary artery bypass surgery through limited access and extending to complex and combined procedures. In the current issue of JTCVS Techniques , Shah and colleagues 2 present their series of aortic root replacements (Bentall) performed through upper mini-sternotomy (UMS), comparing it with the standard full sternotomy Bentall procedure. The authors report a single-center, single-surgeon experience of 48 consecutive mini-Bentall procedures completed over a 10-year period.…”